Pharmacy model for methadone,NAS link to demographics

In “Methadone Matters: What the United States Can Learn from the Global Effort to Treat Opioid Addiction,” senior author Jeffrey H. Sabet, M.D., and colleagues write about the lack of access to methadone treatment, in particular, for opioid use disorder (OUD) in the United States. They look at three pharmacy‐based models that exist in other countries. In their article, published online Feb. 6 in the Journal of General Internal Medicine, they promote the model of patients picking up methadone from pharmacies, as is done in, for example, Canada. The study was funded by the National Institute on Drug Abuse (NIDA) (from the United States) and cited by many as a call to reform the current opioid treatment program (OTP) system in the United States, where patients often prefer buprenorphine simply because they don't have to abide by methadone regulations.     

From starter OTP to acquisition by BayMark: A 3‐year journey

BayMark Health Services has acquired Counseling Solutions, a treatment provider focusing on methadone and buprenorphine treatment with locations in Chatsworth, Georgia, and Brasstown, North Carolina. When Zachary Talbott first started working to open his opioid treatment program (OTP) in Chatsworth more than three years ago, he had no plans to sell it (see ADAW, Aug. 17, 2015).     

Briefly Noted

We asked Jerry Rhodes, former top executive at CRC (now Acadia) and a leader in opioid treatment program management, what he thinks of methadone as a medication to be used in primary care to treat opioid use disorder (OUD), as some people — including former Office of National Drug Control Policy Director Michael Botticelli — recommended last year (see ADAW, July 16, 2018). “I take issue with that,” said Rhodes. “Methadone is a dangerous drug in an unregulated environment,” he told ADAW. Buprenorphine is prescribed this way, but “buprenorphine is a relatively safe drug, and methadone isn't,” he said. A veteran of many battles over methadone, including the near‐elimination of opioid treatment programs, Rhodes told ADAW that “you don't give unfettered access to methadone” to patients with OUD. “Be careful what you wish for” is his advice. This has the potential to cause harm, he said. “Only people who don't understand the history of its utilization would recommend this.”     

Briefly Noted

Last week, Scott Gottlieb, M.D., abruptly and surprisingly resigned as commissioner of the Food and Drug Administration (FDA). He has pushed to reduce teenage vaping, been a vociferous supporter of medications to treat opioid use disorder and is noted in the field for his recommendation that methadone and buprenorphine patients should not be terminated from care for use of benzodiazepines. After he announced his resignation on March 5, vaping stocks surged. He was viewed as critical to protecting youths against nicotine and e‐cigarettes. “He was remarkably successful at keeping the agency moving forward at a difficult time and really focused on public health challenges, including the opioid epidemic and drug prices,” said Joshua M. Sharfstein, M.D., a former principal deputy commissioner at the FDA during the Obama administration, who is now a professor of health policy at the Johns Hopkins Bloomberg School of Public Health, told The New York Times. “He surprised a lot of people in his willingness to take some risks for public health.”     

Under 2% of Medicaid‐covered youths get MAT after OD: Study

Fewer than one‐third of youths receive addiction treatment after an opioid overdose, and only one in 54 receive pharmacotherapy (methadone, buprenorphine or naltrexone), a study published in JAMA Pediatrics reports. The researchers urge interventions to link these youths to treatment after an overdose, and call for improving access to medications: methadone, buprenorphine, and naltrexone.     

Briefly Noted

Clayton Stafford died after using Vivitrol, and his family is suing Alkermes, the manufacturer, saying that the medication doesn't adequately treat addiction, compared to buprenorphine and methadone, and that the manufacturer knew this. In the lawsuit, California‐based law firm Lieff Cabraser alleges that Stafford, his parents and his treatment providers were misled into thinking Vivitrol was an appropriate treatment for his opioid use disorder. “Clayton Stafford's tragic death could have been avoided,” notes Lieff Cabraser partner Fabrice N. Vincent, who filed the lawsuit on behalf of the Stafford family. “The well‐reported defects in Vivitrol made Clayton's overdose a near‐foregone conclusion, and had the Staffords received accurate information about Vivitrol's risks and effective deficiencies from Alkermes, they would never have consented to its use by Clayton.” Naltrexone doesn't work to treat addiction and cravings, but just to block the effects of opioids, according to the lawsuit (and many others agree with this). “Because the patient's addiction is not adequately treated, the patient requires indefinite Vivitrol use to merely block the euphoric effects and keep the patient from seeking opiates,” Vincent said. “Patients therefore remain highly likely to relapse despite indefinite use of Vivitrol.” The lawsuit also makes note of Alkermes' direct‐to‐consumer marketing campaign, which extended into influencing the criminal justice system to use Vivitrol. Stafford had been mandated to use Vivitrol. Last year, the Food and Drug Administration issued a warning letter to Alkermes stating that its advertising did not state that stopping Vivitrol can lead to relapse and overdose, as is clearly stated by the label and package insert (see “FDA warns Alkermes about OD risk on Vivitrol ads,” ADAW, Dec. 16, 2019, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32566 ).     

Is counseling ‘required’ with medications to treat opioid use disorder?

In “No Strings Attached: More Opioid Addicts Get Meds Without Talk Therapy,” an article by Beth Schwartzapfel of the Marshall Project published in USA Today May 9 ( https://www.usatoday.com/story/news/investigations/2019/05/09/opioid‐crisis‐drugs‐no‐therapy/1131110001/ ), both sides were excellently reported. Kenneth B. Stoller, M.D., longtime methadone researcher from Johns Hopkins, was quoted as saying that medications without any talking is “selling patients short.” Some Twitter participants immediately charged that Stoller was kicking patients off medication if they weren't participating in counseling (which he doesn't do and the article doesn't say he does), and a protracted debate on Mother's Day led us to ask Stoller himself — who does not tweet — to respond. We copied and pasted the comments so he could see them. His response is below. (To see the Twitter thread, go to https://twitter.com/ADAWnews/status/1127175604959436800 .)     

WELL‐INFORMED INTERMEDIARIES IN STRATEGIC COMMUNICATION

A privately informed sender may influence the decision maker through an intermediary who is better informed than him. I assume that the objective sender and intermediary pass on their best information, while the biased ones prefer a particular action but also have reputational concerns. I show that the biased intermediary selectively incorporates the sender's information to push his agenda, and his truth‐telling incentives always decrease in those of the biased sender. Hence, measures making it more costly for the sender to lie worsen the biased intermediary's distortion, and may make the decision maker strictly worse off. (JEL C70, D82, M31)     

Briefly Noted

A report from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control and Prevention published in Drug and Alcohol Dependence this month, based on a national survey of 46 opioid treatment programs (OTPs), concludes that buprenorphine and Vivitrol are not given equal footing with methadone as medications used by OTPs. All three are approved by the Food and Drug Administration for the treatment of opioid use disorder. Barriers, including costs, are identified. In addition, the report charges that services for HPV, HIV and other infectious diseases are not adequately integrated into OTPs, and that the reach of OTPs should be expanded. The report, “Characteristics and Current Clinical Practices of Opioid Treatment Programs in the United States,” is by Christopher M. Jones and colleagues; Elinore F. McCance‐Katz, M.D., Ph.D., is the senior author.     

Physicians,hospital face $9 million lawsuit following fatal OD

Two years ago, Victor Williams, a 56‐year‐old Black man, died from a fatal overdose of fentanyl and fentanyl analogs. He was at home, but his family didn't have any naloxone, because he had not been given any by his treatment provider, despite multiple previous ODs. He had an opioid use disorder (OUD) and instead of being prescribed methadone or buprenorphine, he was prescribed Schedule II analgesics in the hospital. Just hours before his fatal OD, the hospital discharged him after an accidental heroin poisoning.     

EXPERTS AND THEIR RECORDS

A market where short‐lived customers interact with long‐lived experts is considered. Experts privately observe which treatment best serves a customer, but are free to choose more or less profitable treatments. Customers only observe records of experts' past actions. If experts are homogeneous there exists an equilibrium where experts always choose the customer's preferred treatment (play truthfully). Experts are incentivized with the promise of future business: new customers tend to choose experts who performed less profitable treatments in the past. If expert payoffs are private information, experts can never always be truthful. But sufficiently patient experts may be truthful almost always. (JEL C73, D82)     

One physician's path to addiction medicine

Ajay Manhapra, M.D., began his medical career as a hospitalist. Eventually, he became an addiction treatment specialist. He described his path to addiction medicine in an interview with ADAW last month.